Introduction

This report describes specialty substance abuse treatment services in the U.S., based on the National Drug and Alcoholism Treatment Unit Survey (NDATUS). (1) The survey queries specialty providers of substance abuse treatment, including facilities that only treat substance abuse (called free-standing), and specialized units within multi-purpose institutions such as hospitals. The survey is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), in collaboration with the States. Other Federal agencies also participate by identifying treatment facilities that they support.

NDATUS solicits data concerning provider and client characteristics from a census of all identified providers. These data pertain to a specific reference date. For the 1992 survey, it was September 30, 1992. Provider characteristics include institutional setting, ownership, treatment services, and source of funding. Client characteristics are summarized by counting people who are actively enrolled by substance of abuse (alcohol, drugs, or both), sex, age, race/ethnicity, IV (injection) drug use, pregnancy, HIV status, and waiting list.

The census involves all providers identified on the National Facility Register (NFR, formerly called SAFIS). Providers listed on the NFR were identified primarily by State and Federal agencies that fund, license, or regulate specialized substance abuse intervention services. The NFR identifies treatment providers primarily, but it also includes organizations that deliver prevention services and providers of other services related to treatment such as central intake and assessment of prospective clients. Some privately owned and funded providers are not identified by public agencies but nonetheless respond to the survey. Survey response is motivated in part as a marketing tool. Responders are identified in the National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs [SAMHSA 1993b] and this directory is used by many as a referral source.

The NDATUS survey is one of two sources of national data on specialty substance abuse treatment. The other source is the Client Data System (CDS). Also a collaboration between SAMHSA and the States, CDS is an ongoing administrative reporting system that collects individual client admission records from State funded or monitored providers [see SAMHSA 1994a, pp.18-43, for CDS data as compiled by individual States]. In FY92, CDS collected a consistent series of admissions records from 40 States plus the District of Columbia and Puerto Rico, an area representing 89% of the nation's population. CDS results will be published in a forthcoming Advance Report. An integrated analysis of NDATUS and CDS data will also be included in a forthcoming Main Findings report.

Like previous NDATUS reports, this report updates the ongoing series of NDATUS survey results. However, unlike previous reports, it makes explicit comparisons to results from prior surveys, starting in 1980. That is the first year when the current set of demographic data was collected for both alcohol and drug clients. NDATUS or precursor surveys were conducted annually from 1973 to 1980, in 1982, 1984, and 1987, and annually again from 1989 to 1992. However, because of reporting limitations prior to 1992, comparisons are limited to proportionality relationships, such as the percentage of women in the treatment population and the percentage of providers reporting from within general hospitals. Actual numbers of clients cannot be compared because critical non-respondent data were not collected prior to 1992.

Also for the first time, this report makes explicit graphic comparisons among the States in order to highlight differences in the number of clients in treatment, in their substance abuse problems, and in treatment services delivered. These differences may reflect many factors, such as the number of people who need substance abuse treatment, the pattern of substances abused, clients' ability to pay for treatment, the availability of private insurance and public funding for treatment, social mores, cultural values, criminal justice sanctions, and the data definitions and collection process. NDATUS does not collect the broad range of data needed to explain why specialty providers and clients differ among States. Nevertheless, State differences are highlighted because they are sufficiently large to suggest major differences among State substance abuse treatment policies.

In addition to changes in data analysis, the 1992 NDATUS introduced a representative sample survey of non-responders to the main survey, and imputation of key data when respondents did not complete all questions. These changes permit estimation of basic provider and client characteristics for the entire 1992 NFR universe of specialty treatment providers.

Limitations

All surveys have limitations that must be understood before their results can be fully appreciated. Four limitations are noted here and more fully described in Appendix 3.

First, NDATUS collects limited services data for one reference day out of the year. This one-day snapshot is a good indicator of the scope and costs of annual treatment services to the extent that admissions, the duration of treatment episodes, and the content of treatment services are stable over time. Regarding the flow of admissions and the duration of treatment episodes, there is evidence of stability. Admissions records reported to CDS indicate that admissions are relatively stable over the year [see forthcoming CDS Advance Report]. Regarding the duration of treatment episodes, joint analysis of 1992 NDATUS and CDS data yield estimates that roughly match estimates from a 1990 national sample of clinical records [SAMHSA, DSRS, 1992 and forthcoming Main Findings].

It should also be understood that the distribution of clients (for example the percent in 24-hour care) reported in a one-day census will differ from the distribution reported annually to CDS. Both time perspectives are important in trying to understand treatment activity and its costs and benefits to society. An annual viewpoint, however, highlights the relative contribution of shorter term (and often more intense) 24-hour treatment programs which accumulate treatment episodes more rapidly over time than longer term, outpatient programs.

Second, the NFR universe targeted by NDATUS has not been fully developed as a standardized list of all locations where specialty services are delivered. It should include nearly all recipients of State and Federal funds because the States both disperse these funds and identify NFR providers. However, since 1987, the States have had the option of identifying centralized administrative organizations that may manage many different treatment locations. As a result, two or more treatment facilities may be nested within each provider listed on the NFR. Also, the target universe is broadly defined, allowing considerable discretion for the States and Federal agencies. Some States may include all providers, public and private, because they license or otherwise regulate all specialty treatment. Other States do not monitor providers that rely exclusively on private funds, and thus do not identify them for the NFR.

Third, beyond three broad categories and eight types of treatment, NDATUS does not collect data on the content of specialty treatment. Nor does it allow longitudinal tracking of clients that is needed in order to assess treatment outcomes. However, information about how treatment services vary among providers will be collected by the National Treatment Study, a 1995 sample survey sponsored by SAMHSA. Except to the extent that NDATUS and CDS report changes in the number of clients by treatment categories, there is little national information about how the content of treatment has changed over time.

Fourth, some differences in NDATUS data reported over time may be artifacts resulting from changes in NDATUS procedures or reporting practices. An example is the 1987 policy change discussed above involving one provider reporting for several treatment locations. Other factors that could affect comparability over time include variation in coverage and response rates (nationally and among States), changes in the NDATUS form, and variation in Federal and State resources available for conducting the survey. Finally a major difference between the 1992 survey and previous surveys is the introduction of non-response adjustments.

Regarding differences among the States, it is important to note that NDATUS is a collaboration between SAMHSA and each State and jurisdiction. As a result, comparisons over time and the quality of the data in general depend upon independent decisions made by the more than 50 governments involved.

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